<i>Annals</i> for Educators - 19 July 2016
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2016)

Web Exclusives19 July 2016Annals for Educators - 19 July 2016FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201607190 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsComparative Effectiveness of Tai Chi Versus Physical Therapy for Knee Osteoarthritis. A Randomized TrialStudies of patients with osteoarthritis have found improved outcomes with Tai Chi, a traditional Chinese mind–body practice, compared with usual physical activity, wait-list, or attention control groups. No trials have compared Tai Chi and standard treatments for osteoarthritis. This article reports the findings of a 52-week trial comparing Tai Chi with physical therapy for treatment of knee osteoarthritis.Use this study to:Review the evaluation of knee pain. What questions should be asked? What is the differential diagnosis of osteoarthritis of the knee? Use the information in In the Clinic: Osteoarthritis to help prepare a teaching session.Teach at the bedside! Have your learners practice examining each other's knees and then examine patients with osteoarthritis and other causes of knee discomfort. There are likely several on your service in the hospital, even if not the reason for admission.Ask a radiologist if she or he would assemble a few teaching images of key radiographic findings of the knee to review with your team.Ask a physical therapist to join your discussion of this paper's results and explain what a patient referred to therapy for knee osteoarthritis will be provided.Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of PhysiciansPsychological and Behavioral Interventions for Managing Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of PhysiciansPharmacologic Treatment of Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of PhysiciansThese new guideline recommendations from the American College of Physicians provide evidence-based advice for the management of chronic insomnia disorder in adults. Implementation of these guidelines requires major changes in practice. The accompanying evidence reviews provide detailed information regarding the studies used by the guideline group when formulating its recommendations.Use these papers to:Start a teaching session with a multiple-choice question. We've provided one below.Ask your learners how they evaluate a patient who reports insomnia. What is the differential diagnosis? Are any tests indicated? Use the information in In the Clinic: Insomnia .Ask your learners how one refers a patient for cognitive behavioral therapy (CBT). What are the barriers? Is it readily available? Use the accompanying editorial to help frame your discussion. Invite an expert in CBT tell your group what is involved and to demonstrate its practice with your learners.The guideline recommends CBT as initial therapy for insomnia. How would your learners explain this to a patient, who may want a “pill to help me sleep”? CBT involves more “effort” by the patient than taking a pill. How will your learners explain this, and will they be able to convince a patient to try?Review the pharmacologic treatments available for insomnia. Note the potential advantages, as well as the harms, of each. Use the guideline's figure to help. Ask your learners when pharmacologic therapy would be appropriate, and how they would choose the appropriate agents for their patients.Realizing HOPE: The Ethics of Organ Transplantation From HIV-Positive DonorsThe HIV Organ Policy Equity (HOPE) Act now allows transplantation of organs from HIV-positive living and deceased donors to HIV-positive individuals with end-stage organ disease in the United States. The authors discuss the ethical opportunities and challenges.Use this paper to:Ask your learners why access to organ donation has historically been severely limited for HIV-positive individuals. Why has thinking in this area changed?What are the potential risks to an HIV-positive patient specifically to undergo organ transplantation? What additional risks are there to receipt of an organ from an HIV-positive donor?Do your learners think it is “fair” to provide HIV-positive organs to HIV-positive recipients as a means of increasing their access to treatment? Why or why not?Video LearningThe Consult Guys: Are Those Ventricular Premature Contractions Really Benign?In this episode, The Consult Guys grapple with whether ventricular premature contractions (VPCs) pose a problem.Use this feature to:Watch the brief video with your learners.Ask when an evaluation of VPCs is necessary. What testing should be performed?Is suppressive therapy ever needed for VPCs?Focus on Graduate Medical EducationFinancing U.S. Graduate Medical Education: A Policy Position Paper of the Alliance for Academic Internal Medicine and the American College of PhysiciansIn this position paper, the Alliance for Academic Internal Medicine and the American College of Physicians make a series of recommendations to reform the current funding system to better align graduate medical education with the nation's health care workforce needs.Annals for HospitalistsAnnals for Hospitalists - 19 July 2016Inpatient Notes: Hospitalists and Digital Medicine—Overcoming the Productivity ParadoxThis new monthly Annals feature is designed especially for busy hospitalists by simplifying your search for information that matters most to you. Developed by and for hospitalists in collaboration with the University of Michigan Hospital Medicine Program, Annals for Hospitalists highlights the most relevant content from Annals of Internal Medicine and ACP Journal Club. In addition, a monthly commentary, Inpatient Notes, provides unique perspectives on contemporary topics in hospital medicine. This month's alert highlights recent findings regarding hospital-acquisition of Clostridium difficile infection, the risk for heart failure among users of antihyperglycemic drugs, the inpatient treatment of gout, discusses pitfalls in contracts for employed physicians, and more. Dr. Robert (Bob) Wachter, a founder of hospital medicine, discusses the proliferation, promise, and peril of health care's digitalization in this month's Inpatient Notes. We hope you enjoy this new feature!MKSAP 17 QuestionA 42-year-old man is evaluated for a lifelong history of insomnia. He reports always having had trouble sleeping, but sleep initiation and maintenance have become more difficult over the past few years. He experiences daytime sleepiness but does not have the opportunity to nap. He reports no depressed mood or anhedonia. His wife has not noticed excessive snoring or abnormal or absent breathing during sleep. He drinks one cup of coffee in the morning and drinks one alcoholic beverage 3 to 4 nights per week. Medical history is otherwise unremarkable. He takes no medications.On physical examination, the patient is afebrile, blood pressure is 142/82 mm Hg, pulse rate is 78/min, and respiration rate is 14/min. BMI is 27. The remainder of the physical examination is normal.Which of the following is the most appropriate next step in management?A. Alcohol cessation counselingB. Sleep hygiene counselingC. TrazodoneD. ZolpidemCorrect AnswerB. Sleep hygiene counselingEducational ObjectiveTreat a patient with chronic insomnia.CritiqueThis patient with chronic insomnia should undergo counseling regarding sleep hygiene. Insomnia is defined as the inability to initiate or maintain adequate sleep and is a common disorder. It can lead to daytime somnolence, work absenteeism, motor vehicle accidents, poor general health, functional impairment, and impaired quality of life. The initial management of insomnia focuses on implementing good sleep hygiene, which refers to the optimization of the environmental and behavioral factors associated with sleep. Patients should be advised to establish a regular relaxing bedtime routine; associate the bed and bedroom with sleep; avoid increasingly common disruptors of sleep such as cell phone, television, or computer use in the bedroom; adhere to a stable bed time and arising time; and keep the room quiet and dark.Alcohol disrupts continuous sleep; however, this patient's modest alcohol use is unlikely to be contributing to his chronic and progressive insomnia.Antidepressant therapy may improve sleep difficulties in the depressed patient. In addition, some antidepressants, including trazodone, doxepin, and mirtazapine, have sedative side effects, which can be used to advantage in a depressed patient with significant insomnia. Doxepin, in doses lower than needed for an antidepressant effect, is the only antidepressant agent approved for the treatment of insomnia. This patient does not manifest other symptoms of depression, and treating insomnia in the absence of depression with antidepressant agents other than doxepin is not indicated.Zolpidem is a short-acting nonbenzodiazapine that is used in the treatment of insomnia. Because of potential adverse effects, the use of pharmacologic agents such as zolpidem should be considered only after attempts at behavioral therapy and other nonpharmacologic interventions have failed.Key PointThe initial treatment of insomnia focuses on implementing good sleep hygiene, which refers to the optimization of the environmental and behavioral factors associated with sleep.BibliographyMasters PA. In the clinic. Insomnia. Ann Intern Med. 2014;161:ITC1-15; quiz ITC16. doi:10.7326/0003-4819-161-7-201410070-01004Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 19 July 2016Volume 165, Issue 2Page: ED2KeywordsCognitive behavior therapyGraduate medical educationHospital medicineHospitalistsHygieneInpatientsInsomniaKneesOsteoarthritisSleep ePublished: 19 July 2016 Issue Published: 19 July 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.Loading ...